Improving Quality and Performance - Brandeis University
Improving Quality and Performance:
Cultural Competence and Workforce Diversity Strategies
January 2016
Introduction
The healthcare business landscape is changing. In the wake of the
Patient Protection and Affordable Care Act (ACA), newly insured
individuals are seeking health care outside of the emergency
department setting, bringing an increasingly diverse patient population
into the healthcare system. Newer payment models, including valuebased purchasing and pay-for-performance programs, create new
imperatives for hospitals and healthcare systems to contain costs while
improving patient outcomes and ensuring the quality of care for all
populations.
The increased emphasis on quality and cost-containment means that
many healthcare organizations are seeking to develop and implement
innovative approaches to service that incorporate new performance
measures. With guidance, more healthcare organizations can expand
upon their progress in this area, improving healthcare services, quality,
and health outcomes, while having broad community impact.
The Bottom Line
Improved staff retention, increased
market share, and reduced medical
liability expenses are tangible returns on
investments in organizational strategies
that increase workforce cultural
competence and diversity.1
Hospitals and healthcare systems that
understand their patient populations
and make quality improvements across
all demographic groups will improve
overall performance.2
Increasing the diversity of the healthcare
workforce improves patient satisfaction,
A key area of focus for these hospitals and healthcare systems is
healthcare utilization patterns, and
organization-wide cultural competence and workforce diversity, or
access to care for minority patients.3-5
cultural effectiveness. Achieving cultural effectiveness is predicated
upon successfully targeting seven elements ¨C leadership, institutional
Cohen, E., & Goode, T. (1999). Rationale for cultural
policies and procedures, data collection, community engagement,
competence in primary care (Policy Brief No. 1).
Washington, D.C.: National Center for Cultural Competence,
language and communication access, staff cultural competence,
Georgetown University.
1
and workforce diversity and inclusion. Research demonstrates that
Mayberry, R., Nicewander, D., Qin, H., & Ballard, D. (2006).
Improving quality and reducing inequities: A challenge
management practices and administrative policies designed to build
in achieving best care. Baylor University Medical Center
a culturally effective organization can improve patient and employee
Proceedings, (19)2, 103-118.
LaVeist, T., & Nuru-Jeter, A. (2002). Is doctor-patient race
satisfaction, the quality of clinical care delivered, and patient health
concordance associated with greater satisfaction with care?
2
outcomes. High performance in the areas of staff cultural competence
Journal of Health and Social Behavior, (43)3, 296-306.
and workforce diversity can result in an enhanced bottom line resulting
Hampers L., Cha S, Gutglass D., Binns H., & Krug S. (1999).
Language
barriers and resource utilization in a pediatric
from patient satisfaction-based performance incentives. Increased
emergency department. Pediatrics, 103(6 Part 1), 1253-1256.
workforce diversity and cultural competence can also lower costs
Mitchell, D., & Lassiter, S. (2006). Addressing health care
disparities and increasing workforce diversity: The next
as a result of increased employee retention, more efficient use of
step for the dental, medical, and public health professions.
interpreter services, and a reduction in unnecessary care and avoidable
American Journal of Public Health, (96)12, 2093-2097.
readmissions that can follow when communication and cultural
understanding improve.3 For these reasons, it is just as important to
understand the needs of the various racial and ethnic groups that
contribute to the rapidly increasing diversity in an organization¡¯s catchment area as it is to understand the differing needs
of the baby boomer and millennial market segments to which organization are trying to respond.
1
2
3
4
5
Although all seven elements contribute to success in becoming a culturally effective organization, this brief focuses
on specific indicators and approaches that tie service, quality, and outcomes to the implementation of organizational
strategies to improve workforce diversity and cultural competence. In addition to providing an overview of research in
the field, the brief includes case studies and resources to facilitate the creation of a strategic plan.
Healthcare Disparities Increase Costs ¨C Culturally Effective Organizational Practices Increase Value
Healthcare disparities raise the overall cost of health care. If not actively addressed, a significant area of potential
cost-savings will remain unchanged, impacting the healthcare system and broadly impacting community health.
For example, minority women in New Hampshire are three times as likely as non-Hispanic Caucasian women to
be diagnosed with cardiovascular disease.4 The cancer-related death rate in New Hampshire is almost twice as high
for non-Hispanic Black women as it is for Caucasian women: 294 per 100,000 non-Hispanic Black women and
150 per 100,000 Caucasian women.5 To address variation in treatment and outcomes, government, private payers,
and healthcare accrediting bodies are emphasizing the importance of cultural effectiveness.6 Culturally effective
organizations enable, cultivate, and support the delivery of high-quality health care for all groups of people.7 Work in
this area is already underway to address gaps in health equity in New Hampshire.8
Research shows that employing a workforce that reflects the cultural, ethnic, and linguistic diversity of the
community an organization serves, while simultaneously achieving cultural competence benchmarks, can
have multiple benefits. These benefits can include a reduction in average inpatient length of stay and avoidable
readmissions, an increase in treatment adherence, improved patient satisfaction ratings, more appropriate service
utilization patterns, and enhanced operating efficiencies.9 Thus, workforce diversity and cultural competence
strategies can play an important role in organizational efforts to improve financial results and enhance services for an
increasingly diverse population.
Documented Cost-Savings
The Case for Change
Healthcare organizations that have diversified their
workforce and enhanced their cultural effectiveness report
numerous beneficial outcomes for patients and for the
businesses themselves. There likely are additional benefits
that have not been reported publicly, as these efforts are
works-in-progress. Research on the impact of workforce
diversity and cultural competence has found that:
Service Utilization
? Decreased inappropriate utilization1
? Shortened length of stay1
? Increased utilization of profitable services1
? Expanded total number of patients1
?
Healthcare workforce diversity affects patient health
outcomes, treatment adherence, safety, satisfaction, and
quality of care.10
?
Workforce diversity is associated with improved patientprovider communication.11
Staff Productivity
? Improved discharge capacity1
? Enhanced overall productivity1
?
Racial and ethnic concordance in patient-provider
relationships can increase patient engagement.12
?
Patients with limited English-speaking abilities have
better health outcomes, receive higher quality care, and
report higher satisfaction when they have access to trained
professional interpreters and bilingual/multilingual staff
members.13
Meeting Joint Commission Standards
? Serve patients¡¯ communication needs2
? Accommodate patients¡¯ cultural and
ethnic needs2
?
2
Language Interpretation
? Lower contract interpreter costs1
? Reduced communication delays between
providers and patients1
? Reduced system inefficiencies (e.g., wait
time for interpreters)1
Organizations that possess greater levels of cultural
competence earn higher scores on the Hospital Consumer
Assessment of Healthcare Providers and Systems
(HCAHPS) survey in the areas of communication, effective
pain control, and staff responsiveness.14
Cobb, A.J. (2007). Making the business case for culturally
and linguistically appropriate services in health care:
Case studies from the field. Washington, D.C.: Alliance of
Community Health Plans Foundation. Retrieved from http://
minorityhealth.Assets/pdf/Checked/CLAS.pdf
2
The Joint Commission. (2014). A Crosswalk of the National
Standards for Culturally and Linguistically Appropriate
Services (CLAS) in health and health care to The Joint
Commission Hospital Accreditation Standards. Retrieved
from
1
Definitions
Culturally Effective Organization
An organization with leadership
that formally acknowledges the
importance of organizational
cultural competence through policysetting, organization-wide training,
performance monitoring, data
collection, patient communication,
care delivery that is sensitive to
diverse needs, targeted human
resources strategies, and community
engagement.15
Cultural Competence
A set of attitudes, skills, behaviors,
and policies that enable staff
members to work effectively in crosscultural situations.16
Workforce Diversity:
A workforce composed of a range of
diverse employees (by culture, race/
ethnicity, language, etc.) represented
at all levels of the organization.i
Workforce Inclusion
Creating an accepting environment
where differences are honored, all
employees feel valued and respected,
and where staff members have the
confidence to do their best work.17
Racial and Ethnic
Healthcare Disparities
¡°Racial or ethnic differences in
the quality of health care that are
not due to access-related factors
or clinical needs, preferences, [or]
appropriateness of intervention.¡±18
Examples of Performance Measures
Clinical Measures Disaggregated by Race/Ethnicity & Language Status
? Ambulatory care-sensitive readmissions1
? Avoidable emergency room visits2
? Length of stay measured in hours2
? Inappropriate test ordering2
? Sentinel disparity indicators (e.g., pain management in the emergency
department)3
? HEDIS outcome measures
Patient & Employee Satisfaction Disaggregated by Race/Ethnicity &
Language Status
? Patient satisfaction scores4
? Number of patient complaints
? Diverse employee satisfaction scores5
? Employee discrimination complaints5
Cultural Competence
? Pre/post staff cultural competence training knowledge assessment scores
? Chart review documenting clinician behavior change6
? Patient experience questions disaggregated by race, ethnicity, and language
Operations
? Waiting time for new clinical appointments for those requiring interpreters7
? Cost of contract interpretation services1
? Number of in-person vs. telephone interpreter contacts1
Human Resources Disaggregated by Race/Ethnicity
? Staff hiring, retention, and advancement rates
? Staff absenteeism
? Demographic composition of senior leadership and board of directors8
? Proportion of diverse employees at each job level9
Cobb, A.J. (2007). Making the business case for culturally and linguistically appropriate services in health
care: Case studies from the field. Washington, D.C.: Alliance of Community Health Plans Foundation.
Retrieved from
2
Betancourt, J. (2006). Improving quality and achieving equity: The role of cultural competence in
reducing racial and ethnic disparities in health care. Retrieved from
3
Thorlby, R., Jorgensen, S., Seigel, B., & Ayanian, J. (2011). How health care organizations are using data on
patients¡¯ race and ethnicity to improve quality of care. The Milbank Quarterly, 89(2), 226-255.
4
Health Research & Educational Trust. (2013). Becoming a culturally competent health care organization.
Retrieved from
5
Brenman, M. (2012, November 24). Diversity metrics, measurement, and evaluation. Retrieved from
6
Betancourt, J., & Green, A. (2010). Linking cultural competence training to improved health outcomes:
Perspectives from the field [Commentary]. Academic Medicine, 85(4), 583.
7
U.S. Department of Health and Human Services, Health Resources and Services Administration. (2001).
Cultural competence works: Using cultural competence to improve the quality of health care for diverse
populations and add value to managed care arrangements. Retrieved from
8
American Hospital Association. (2004). Strategies for leadership: Does your hospital reflect the
community it serves?: A diversity and cultural proficiency assessment tool for leaders. Retrieved from
9
Gallagher-Louisy, C. (2013, July). The ROI of D&I: Why municipalities must measure their efforts
in equity, diversity and inclusion. Retrieved from
mw-roi/
1
In this document, use of the term ¡°diversity¡± is limited to racial, ethnic, and linguistic diversity. However, creating a culturally effective organization
requires attention to all aspects of diversity, including age, gender and sexuality, physical and mental disabilities, religion, etc.
i
3
Measuring Success
A wide variety of resources and tools are available for those looking to measure the success of their workforce diversity
and/or cultural competence strategies. In addition to consultancies that specialize in advising organizations on such
assessments, printed and electronic tools are available for those who choose to assess their outcomes independently
(see Resources). Some of these tools also may be useful for assessing organizational readiness in the period leading up
to accreditation visits, or in assessing progress toward meeting Enhanced National CLAS Standards.19 For example,
users of a cultural competence assessment tool created by The Lewin Group indicated that the instrument was helpful
in preparing the organization for a Joint Commission accreditation visit.20
Measuring progress within both the inpatient and outpatient environments can provide the organization¡¯s leadership
with rich data that may highlight a need for broader strategies or validate the wide-reaching success of current work.
This can be approached by measuring smaller organizational units. For example, organizations may measure and make
comparisons across departments and hospital-affiliated practices.21 The following table provides additional examples of
useful approaches to the assessment process.
Select Evaluation Research Options
Type of Assessment
4
Unit of Measure
Possible Measures
Primary Audience
Patient satisfaction
Individual
Number of patient and family complaints, satisfaction with quality of care received, self-reported patient understanding of discharge
instructions, and satisfaction with interpreter
services (if used)
Leadership, clinical staff, Patient and
Family Advisory Council (PFAC),
and community leaders
Patient and staff
demographics
Individual
Patient and staff member race, gender, age,
primary language, etc.
Leadership, clinical staff, and human
resources
Patient health
outcomes (to
identify treatment
variation)
Individual
Quantitative clinical health outcomes
(e.g., post-visit BP or A1c, mortality rates,
nosocomial infection rates) and patient-reported outcomes (e.g., incidence of difficulty
performing ADL)
Leadership and clinical staff
Community needs
Catchment area
Environmental scan of services already in
existence, analysis of services needed, trends
in community demographics, etc.
Leadership, PFAC, and community
leaders
Operations
Organization
Cultural appropriateness of meal selections,
signage, patient education materials, and
legal documents (both complexity and
language interpretation)
Leadership, PFAC, and legal counsel
Staff cultural
competence
Organization
and individual
Knowledge, attitude change, and evidence of
behavior change (e.g., documented through
clinical chart review)
Leadership, human resources, and
community leaders
Staffing
Organization
Staff diversity, retention rates, and grievance
rates disaggregated by race/ethnicity and
primary language
Leadership and human resources
Key Lessons from the Field and the Literature
Healthcare organizations that implement and evaluate cultural competence and workforce diversity strategies learn
important lessons along the way. Some have found that engaging ¡°linguistically appropriate services¡± is the best first
step toward cultural effectiveness.22 Focused attention on the professional development of bilingual and multilingual
employees has been key to many organizations that have achieved cultural effectiveness.23
Performance assessment during and after the implementation of cultural competence and workforce diversity
interventions should be part of any planned effort.24 It is essential to strive to collect high-quality data. High-quality
data helps ensure the rigor and usefulness of performance assessments intended to measure success. Through
interviews with key researchers in the field, as well as a review of the literature, the authors have identified both dataspecific lessons, as well as general lessons, that are applicable to most healthcare organizations that seek to move
forward with their cultural effectiveness work.
Conceptualize the Performance Assessment
Develop a common understanding of how the organization defines cultural competence, workforce diversity and
inclusion, and disparity.
? Identify the organizational level that the intervention is designed to impact: a) the entire organization, b) a single
department or sub-group, or c) individuals involved directly or indirectly with care delivery.
? Delineate specific desired changes, such as clinical process, clinical outcomes, employee behavior change, reduction
in adverse health events, return on investment, etc.
? Determine which process and/or outcome variables would best measure the desired changes.
? Design an intervention drawing on existing evidence linking cause and effect for the challenge being addressed.
? Include culturally and linguistically diverse staff and/or external stakeholders in the planning and implementation of
the intervention.
?
Ensure Quality of Data
Collect baseline data to compare to future data collection periods.
Consider whether there will be enough data to generate statistically significant results. If samples are small, consider
combining data collected during a longer time period.
? Make use of qualitative methods (e.g., interviews and focus groups) to help explain quantitative findings from
surveys, etc.
? Use direct measures of minority patient experience on patient surveys (e.g., measures of patients¡¯ perceptions of staff
cultural sensitivity, respect, and discrimination).
? Disaggregate the data by race, ethnicity, and language during analysis to determine whether different outcomes exist
for diverse groups.
?
?
Facilitate Data Collection and Access
Update race, ethnicity, language, and contact information on an ongoing basis when patients go through the
registration process to save time and money, as well as to facilitate the sampling process that occurs before an
internal assessment.
? Use multiple methods of data collection when gathering feedback from diverse patients to ensure their ability to
participate if facing language or other barriers (e.g., focus groups offered in languages other than English).
? Provide patients with easy-to-understand materials in multiple languages and use interpreters to ensure
communication access and full patient participation in assessments.
? Ensure that patient race, ethnicity, and language information is shared across the organization and available to all
staff who have access to patient records (e.g., clinical, billing, etc.).
?
5
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